Analysis General The examination of the helicopter did not reveal any technical anomalies. Therefore, this analysis will focus on environmental factors, the pilot's decision to conduct the final trip to GoByPoint and return, and the survival and organizational factors. The weather encountered during the day's flying was generally consistent with the GFA. There were VFRconditions throughout most of the period, but with scattered towering cumulus clouds (TCUs) giving areas of sm visibility in snow showers; conditions that were below the operator's VFRlimit of 1sm. On two occasions before the accident flight, the pilot had encountered brief but heavy snow showers. On both occasions, the pilot complied with instructions in the OM and took appropriate alternate action. The first occasion required a landing near Marystown, and the second required a ground delay at the WinterlandAirport. The Accident Flight There is no direct information about the pilot's decision making related to the final flight of the day from Marystown to GoByPoint and return. Although there were still TCUs in the area, the weather at Marystown before the departure was suitable for visual flight, and Go By Point was only a few minutes of flying time away with sunny and clear weather. The pilot, who was highly experienced in these operations, had earlier dealt successfully with a snow squall in MortierBay. It is likely that the pilot believed that the trip to GoByPoint and the return to Marystown could be completed safely and before dark. The weather encountered by HMCSGooseBay and the images from the security camera near CowHead indicate that the weather in the northern part of MortierBay worsened considerably shortly after CG352 landed at GoByPoint. Conditions in the northern part of the bay were, at times, well below sm. While on the landing pad at GoByPoint, the pilot would have had only a limited view of the sky to the northwest, the direction from which the worsening weather conditions were approaching. When the helicopter departed Go By Point to return to Marystown, only light snow was falling. It appears that the weather conditions prevented a direct flight to Marystown and that the pilot chose to fly the slightly longer route around the northern perimeter of MortierBay (see AppendixA). However, the helicopter would have gradually encountered heavier snowfall as it flew north and then west over the coast towards Marystown. Once established on a westerly heading towards Marystown, it would have been difficult to turn around when severely reduced visibility was encountered because a turn to the right would have required flight into rapidly rising terrain with a possibility of encountering whiteout conditions. A turn to the left would have placed the helicopter out over the water and caused the pilot to lose visual contact with the coast. With the need to maintain constant attention to outside visual cues, the pilot would have been experiencing an increased workload. This may have distracted him from selecting the particle separator, engine anti-ice, and continuous ignition switches that are required for flight in snow, and from arming the pop-out floats as he reduced airspeed below 60knots in reduced visibility over the water. The helicopter continued along the northern coast until MortierBay narrowed, then executed a left turn towards the east (downwind), likely in an attempt to return to the better weather conditions at GoByPoint. Maintaining a reduced groundspeed in lowered visibility, as prescribed in the OM, would have been difficult in the gusty downwind (30knots) conditions over the water. The pilot may have lost sight of land as the helicopter flew across the opening to LittleBay. Reduced visibility in darkness and re-circulating snow, lack of fixed visual references over the water, and turbulence may all have contributed to pilot disorientation. It is likely that the pilot flared rapidly to slow the helicopter. The tail contacted the water heavily, breaking off and causing the subsequent loss of control. Survival Equipment Installations Because there was no emergency signal to notify SAR of the accident, rescue efforts were not initiated until one hour after the flight planned estimated time of arrival. Without a liferaft, the pilot and passenger were not equipped to survive prolonged cold water immersion. In the absence of an ELT signal, initiation of a SAR response relies on either witness action or the flight plan notification time. The survival equipment installed on the accident helicopter exceeded regulations. However, it was not available to assist the survivors after the accident. The existing regulations may be appropriate in the event of a successful controlled ditching, but they do not ensure protection during a capsizing event. Had electronic SAR signalling been available, a search could have begun immediately. Lifejackets The direct flight from Marystown to Go By Point was short and was likely conducted almost entirely over land. The passenger may have been anticipating a similar routing back. This could explain why he was not wearing a lifejacket during the return trip. It is also possible that it was an oversight. If he had worn a lifejacket, he may not have drowned; however, even if he had used a lifejacket, hypothermia would have been an immediate threat to his survival. Immersion Suits Most CCG helicopter operations occur near shore. Therefore, even though the helicopters may be operating over water, immersion suits are not required by either the CARs or the OM because they are typically well within the distance-from-shore requirements. It is common practice during CCG flights for immersion suits to be worn only when mandatory. As a result, pilots and passengers are often exposed to prolonged periods of operations over sometimes frigid water without appropriate protection. The OM requirements for immersion suit use are more stringent than CAR requirements, but are also based on distance-from-shore criteria that are inadequate to ensure proper protection. For survivors in frigid water, the distance from shore is not relevant. Survivors may be injured or suffering from cold shock, which can severely limit mobility. The immediate concern for survivors who are immersed in frigid water is to survive long enough to inflate and enter their liferaft, or to stay alive in an immersion suit until help arrives. Using immersion suits and aviation lifejackets would have increased the chance of survival. Liferaft Mounting Bracket Failure The liferaft was unavailable after the impact because it was pinned against the centre rear passenger seat. If a passenger had been in the centre rear passenger seat, it is possible that the passenger could have been pinned between the liferaft and the seat. There was an increased risk to those on board because the liferaft mounting bracket was not able to withstand a survivable rearward impact. Organizational Issues Safety deficiencies identified during the TSB investigations in 2000 continue to exist in TCASD operations. The non-use of shoulder harnesses, lifejackets, and immersion suits continue. At the time of this accident, the liferaft mount head strike hazard identified in May2005 had not been addressed. BO105pilots were unaware of the hazard, and passengers continued to be carried in the front seat without head protection. The frequency of accidents and serious occurrences, the recurrence of identified operational shortcomings, and the lack of progress in mitigating several identified deficiencies are matters of concern that suggest organizational shortcomings at TCASD. The following TSB Engineering Laboratory reports were completed: LP 136/2005 - ULB Analysis; LP 001/2006 - Instrument Examination; LP 003/2006 - Examination of Tail Rotor Short Shaft. These reports are available from the Transportation Safety Board of Canada upon request. The helicopter encountered a heavy snow shower and, while attempting to fly out of the snow, the pilot likely became disoriented. The pilot lost control of the helicopter when the tail broke off after contacting the water during a rapid flare. The survival equipment fitted to the helicopter sank with it, and was not available to aid the survivors after the accident. The occupants of the helicopter were not wearing sufficient personal survival equipment to enhance their potential survival in the frigid water.Findings as to Causes and Contributing Factors The helicopter encountered a heavy snow shower and, while attempting to fly out of the snow, the pilot likely became disoriented. The pilot lost control of the helicopter when the tail broke off after contacting the water during a rapid flare. The survival equipment fitted to the helicopter sank with it, and was not available to aid the survivors after the accident. The occupants of the helicopter were not wearing sufficient personal survival equipment to enhance their potential survival in the frigid water. Although the liferaft mount had been previously identified as a potential head strike hazard, the passenger was seated in the front seat without head protection. At the time of the occurrence, Transport Canada Aircraft Services Directorate management had not taken steps to mitigate the liferaft mount head strike hazard. The liferaft mount failed, pinning the liferaft against the centre rear passenger seat. The emergency locator transmitters on board sank to the bottom and were not able to signal search and rescue of the accident. Therefore, search and rescue efforts did not begin until one hour after the flight's planned estimated time of arrival. The pilot's egress was impeded by a direct-to-airframe helmet cord connection. None of the passengers flown on the day of the accident were provided with immersion suits, nor were such suits required by the regulator (TransportCanada) or the operator (TransportCanada Aircraft Services Directorate). None of those who flew on CG352 on the day of the accident had received helicopter emergency egress/water survival training, nor was such training required by the regulator (TransportCanada) or the operator (TransportCanada Aircraft Services Directorate). At the time of the accident, the operator had not adequately addressed several identified operational shortcomings. The frequency of accidents and serious occurrences, the recurrence of identified operational shortcomings, and the lack of progress in the mitigation of several identified deficiencies are matters of concern that suggest organizational shortcomings at TransportCanada Aircraft Services Directorate.Findings as to Risk Although the liferaft mount had been previously identified as a potential head strike hazard, the passenger was seated in the front seat without head protection. At the time of the occurrence, Transport Canada Aircraft Services Directorate management had not taken steps to mitigate the liferaft mount head strike hazard. The liferaft mount failed, pinning the liferaft against the centre rear passenger seat. The emergency locator transmitters on board sank to the bottom and were not able to signal search and rescue of the accident. Therefore, search and rescue efforts did not begin until one hour after the flight's planned estimated time of arrival. The pilot's egress was impeded by a direct-to-airframe helmet cord connection. None of the passengers flown on the day of the accident were provided with immersion suits, nor were such suits required by the regulator (TransportCanada) or the operator (TransportCanada Aircraft Services Directorate). None of those who flew on CG352 on the day of the accident had received helicopter emergency egress/water survival training, nor was such training required by the regulator (TransportCanada) or the operator (TransportCanada Aircraft Services Directorate). At the time of the accident, the operator had not adequately addressed several identified operational shortcomings. The frequency of accidents and serious occurrences, the recurrence of identified operational shortcomings, and the lack of progress in the mitigation of several identified deficiencies are matters of concern that suggest organizational shortcomings at TransportCanada Aircraft Services Directorate. The underwater locator beacon did not transmit a detectable acoustic signal.Other Finding The underwater locator beacon did not transmit a detectable acoustic signal. Safety Action Taken Transportation Safety Board of Canada On 20 March 2006, the TSB sent a Safety Information Letter (A060016-1) to TransportCanada (TC) Civil Aviation and Aircraft Services Directorate (ASD) regarding the signal failure of the underwater locator beacon (ULB). On 28 March 2006, the TSB sent a Safety Advisory (A060012-1) to TCASD suggesting that it consider the need to revise its mandatory operations manual requirements for immersion suit use to include the more relevant risk factors related to its helicopters' performance characteristics and operating environment. Survival equipment on the accident helicopter was installed as required by regulation, yet it was not available to assist the survivors after the accident. On 09May2006, the TSB sent a Safety Advisory (A060020-1) to TCASD suggesting that it consider the adequacy of its helicopter survival equipment installations so as to improve occupant survivability in a capsized helicopter event. With respect to direct-to-airframe helmet cord connections, other operators may have aircraft with these connection types and may be unaware that these connections can impede egress in an emergency. On 09May2006, the TSB sent a Safety Advisory (A060019-1) to TCCivil Aviation suggesting that it advise the aviation community that these connection types may impede egress and that an intermediate cord can help mitigate this hazard. In response to this Safety Advisory, TCCivil Aviation published an article in the 4/2006edition of the Aviation Safety Letter explaining the egress hazard related to direct-to-airframe helmet cord connections and suggesting the use of intermediate cords to mitigate the hazard. On 09 May 2006, the TSB sent a Safety Advisory (A060021-1) to TCASD suggesting that, as part of its review of the liferaft mounting bracket Limited Supplemental Type Certificate, it may wish to conduct an analysis of the structure so as to improve its ability to withstand survivable impact forces, particularly rearward. Also, the Safety Advisory suggested that TCASD may wish to consider steps to prevent the mounting bracket and liferaft from jamming against the passenger seat belt mounting bolts should a failure occur. On 02 June 2006, the TSB sent a Safety Advisory (A060023-1) to TCASD suggesting to re-evaluate all levels of its organization so as to become more proactive in identifying risks and deficiencies, and more responsive in communicating and mitigating already identified risks associated with its operations. Helicopter Operations Safety Working Group TC ASD and the Canadian Coast Guard (CCG) have established a Helicopter Operations Safety Working Group to review safety equipment, training, and procedures, and to make recommendations for improvements. This group has taken action on passenger helmets and survival equipment, and is reviewing the policy on wearing immersion suits as well as helicopter egress training. As a result of the efforts of the joint working group, the following actions have occurred: Lifejackets have been standardized for passengers and crews, and reflective tape is to be added to the edging of the cover of the jackets and a large orange patch added to the back. Laser flares have been purchased and sent out to the CCG bases to be attached via a cord and rings to each of the standardized high-visibility Switlik lifejackets, modelHV-35C also identified as S7200-2, and inserted in the customized pouch. Helmets have been purchased and issued for front seat passengers in all helicopters and their use is mandatory in CCG helicopters. The installation of a fixed intermediate helmet cord for both front seat positions in all BO105helicopters is nearing completion. Transport Canada Aircraft Services Directorate TC ASD is in the process of implementing a Safety Management System, adding the position of an assistant chief pilot helicopter position and a flight operation quality assurance position all intended to improve, where necessary, existing communication, documentation, and risk assessment practices. Proposals have been generated for modifying the liferaft rack to prevent head injuries. Underwater Locator Beacon All of the TCASD ULBs within the batch of serial numbers affected by the Dukane recall have been replaced. To determine the extent of the delamination problem, the manufacturer cold tested the 11beacons returned by TCASD. One other beacon was found to have failed in a similar manner. The manufacturer is attempting to determine the cause of the metal delamination and the potential scope of the failure. Once this has been accomplished, the manufacturer will consider a further course of action.